Internet is Public Health - What is Telehealth?

Telehealth and telemedicine promised to bridge the gap for rural and remote communities but we are still quite some distance away from the goal.

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Transcript

SPEAKER_00 0:04

Welcome back to Everything's Hope Health. I'm MJ.

SPEAKER_02 0:07

And I'm Kance.

SPEAKER_00 0:08

Have you used any telehealth services? And if so, what is your experience?

SPEAKER_02 0:13

I sure have.

SPEAKER_00 0:14

Okay.

SPEAKER_02 0:15

In a few different contexts. I have regularly used telehealth for mental health services over the last few years. I have had follow-up appointments with specialists doing telehealth. So like I went in for an appointment and got some tests, and then we did telehealth to do the results, for example. And then I've had actually a couple of like urgent care visits over telehealth, where like I've called into my doctor's office and they've said, we can only see you if you do telehealth. And I'm like, I mean, I'm pretty sure I have pneumonia, but okay, we can do telehealth. Actually, ended up going to the actual urgent care. But no, they're they can see probably many more patients than they could otherwise. Like people who are super sick. Like one time I tested positive for COVID and I just needed to get Paxlovid. And so I called them and I said, I just tested positive for COVID like just today. I wasn't sick before. And so I was able to do a telehealth appointment to get the prescription and not have to go expose people. So that was great.

SPEAKER_00 1:14

That's good. So generally positive impressions?

SPEAKER_02 1:16

I would say positive impressions for me. I will say my understanding, and maybe we'll get to this later. My understanding of the purpose of developing telehealth was to reach hard-to-reach geographies and to give them access to services. But then people who are more affluent have tended to suck up all of the telehealth appointments. And it's actually not having the geographic reach that it had been hoped to achieve.

SPEAKER_00 1:43

That is something that we will revisit very shortly. Put a pin in this.

SPEAKER_02 1:48

A little foreshadowing.

SPEAKER_00 1:49

Yeah, you're very good at this. I don't think I've ever utilized telehealth services proper, though most healthcare systems now utilizes patient-facing online portals, which you can use to communicate with your providers, receive lab results securely, etc. So is EHR telehealth like what counts as telehealth? Let's start with some definitions.

SPEAKER_02 2:07

So about two decades ago, when medicine was starting to incorporate technology, they had terms like digital health and e-health to describe the use of the internet in communication and care delivery. Terms that are now rarely used since the internet is ubiquitous now. Telehealth is an umbrella term that means the use of any form of telecommunication or virtual technology to deliver healthcare, information, or education outside of traditional facilities. This includes provider-to-provider interactions as well, for example, using a Zoom call for a consult, remote training or care coordination, etc. Telemedicine is specifically referring to a portion of telehealth that's clinical, like improving patient outcomes, patient access, patient communication, some of the things that I mentioned at the start of the episode. But honestly, it doesn't seem like anybody gets too upset if you use the terms interchangeably. M-health or mobile health is an additional term that refers to the use of smartphones or other mobile devices to assist in healthcare delivery.

SPEAKER_00 3:01

And this is a small point. It may be silly to look at terms like digital health and e-health now because, well, everything is digital and there's e-health like everywhere. But back then it was actually a massive step forward, right? Remember that you used to have to fax things?

SPEAKER_02 3:14

I had to fax things or photocopy things. I think we've talked before about how I was a nurse's aide in a nursing home and in a hospital.

SPEAKER_00 3:20

Oh, you actually did it.

SPEAKER_02 3:21

And when we would transfer patients, we had to send paperwork, right? And we couldn't give our copy, so we had to photocopy everything. And when we did eventually get an EHR, we would then print paper copies of the lab results that were in the computer because nobody was used to having to check the computer for the lab results.

SPEAKER_00 3:40

So it was uh I know you have to fax those.

SPEAKER_02 3:42

The whole thing.

SPEAKER_00 3:43

Yeah, like it's actually a huge step forward. I think living with modern technology today, we oftentimes forget just how big of a deal it is because it's so ubiquitous now. But this is why when the Obama administration passed the High Tech Act in coordination with the Affordable Care Act, incentivizing the use of EHR in healthcare system, it was a huge deal, right? We both remember what doctor's office used to look like. Like the stacks and stacks of boxes, you know, those traditional brown file boxes of just paperwork.

SPEAKER_02 4:11

Well, and if you were a frequent visitor of your doctor's office, your chart could get to be gigantic. And then people are having to look through these huge paper records.

SPEAKER_00 4:22

Telehealth's history is actually quite interesting, and I want to dig a little bit into this. First, telehealth as a concept is actually quite old. There's no single moment of invention. Many of the sources I found during my cursory browsing cites this event as the impetus of telehealth in the United States. Now, let's play a game. Do you know what a lateral thinking puzzle is?

SPEAKER_02 4:44

Uh I can't say that I know with any level of certainty.

SPEAKER_00 4:48

It's a type of puzzle where the question giver, me in this case, presents a question that at first seems either overly vague or it seems impossible, or there's some curious thing about it. And the guesser, in this case you, needs to ask me a series of yes or no questions to figure out what the answer is. It's 20 questions. Uh kind of, yeah. You're not meant to know the answer right away. You're supposed to think laterally, hence the term lateral thinking puzzle, to figure out what the answer is. This puzzle format is very hit or miss. My wife absolutely hates these puzzles. So uh maybe you will too. But who knows? We'll try. We'll have to try at least once to see if you like this. Okay. The question is: what series of events led the US government to start to significantly invest in telemedicine in the 60s and 70s? You can ask me any yes or no questions.

SPEAKER_02 5:33

Was it the Vietnam War?

SPEAKER_00 5:34

Uh no. You could ask like more general questions to sort of narrow it down. You don't have to go straight to an event.

SPEAKER_02 5:40

Was it related to the economy?

SPEAKER_00 5:42

Nope.

SPEAKER_02 5:43

Was it related to billing?

SPEAKER_00 5:46

Uh no, I wouldn't say so.

SPEAKER_02 5:47

Was it related to producing a product of some kind?

SPEAKER_00 5:52

Uh not directly.

SPEAKER_02 5:53

Was it related to food?

SPEAKER_00 5:54

Nope.

SPEAKER_02 5:55

Animals?

SPEAKER_00 5:56

No. I see you're taking the classic 20 questions approach. Think laterally, outside the box.

SPEAKER_02 6:02

Was it related to outer space?

SPEAKER_00 6:04

Yes.

SPEAKER_02 6:05

Ah, okay. So was it related to going to the moon?

SPEAKER_00 6:09

Uh no, not going to the moon. 60s and 70s.

SPEAKER_02 6:12

Was it related to talking to astronauts when they were in the spaceship?

SPEAKER_00 6:19

Related? I think we're gonna end the question here.

SPEAKER_02 6:21

Okay. This is terrible. I'm so sorry, listeners.

SPEAKER_00 6:26

It's a hit or miss. Like, I really love this puzzle format. Some questions are better than others, of course. But anyway, the point is do you know what Project Mercury is?

SPEAKER_02 6:33

I know the name. I couldn't tell you specifics right now. I'm a little discombobulated today, as we talked about before we started recording for reasons that we cannot get into on tape.

SPEAKER_00 6:42

Um, so Project Mercury is during the first chunk of the space race. They just want to put someone in orbit. So this is not about going to the moon. They just wanted to leave the atmosphere. And there was a lot of concerns about what happens when the human body is in zero G. Like, would our heart stop working? Which is honestly a genuine, serious concern because who knows? Our blood has never been in zero G before. So maybe we'll pass out. So they wanted to have a way to monitor the astronauts as they go up in orbit in zero G. And then they realize that, well, option number one, we send a doctor up there, right? That's option number one.

SPEAKER_02 7:18

Risk killing a doctor when you risk killing an astronaut. Sounds great.

SPEAKER_00 7:22

Yeah, so they're like, probably not. So we need to come up with a way to monitor the crew remotely on the surface of the earth. And there was success. Approach Merbercurry happened, and they were able to set up these monitoring uh systems. And then they realized, well, if we can monitor people in space, surely we could monitor people on the ground. A lot of things came from NASA, a lot of technology was like space exploration. So the US government's like, well, you know, let's start investing in these. And their initial impetus was to reach hard-to-reach places, like you mentioned earlier. So, like rural communities or communities that are really not connected to metropolitan centers. It kind of worked, you know. It was better than before. It was better than not reaching them at all. But we'll get into some of the barriers later in a bit. Telemedicine is a massive discipline, and like public health, it's so broad and diffuse that it's hard to give a general description without providing any examples. It's like when people ask you, oh, what is public health? You're like, Well, everything is public health.

SPEAKER_02 8:21

Of course. That's my answer all of the time.

SPEAKER_00 8:24

Yeah. So here are some examples of what telehealth and telemedicine look like. So we could be a little bit more grounded.

SPEAKER_02 8:29

Previously, a hospital or a clinic would need an in-house radiologist to interpret the images, x-rays, CT, etc. With telemedicine, the images can be taken by a technician and sent to a remote radiologist for interpretation, who then sends the results back. I will say the hospital that I worked at, we partnered with doctors in Australia because the night shift where we are was the day shift for them. Oh, perfect. So it worked out great.

SPEAKER_00 8:54

Yeah, time zones.

SPEAKER_02 8:55

But similar paradigms can be achieved for other specialties. So sending EKG readings for a remote cardiologist, sending over pathology images or EEG or ultrasound recordings, etc.

SPEAKER_00 9:06

Yeah. And the time zone thing, uh, I didn't even think about it, but perfect. If they're up already, might as well do some work. And the internet truly made that distance very short. Consultations over distance reduces the reliance on in-house providers. The consultations with other providers over the internet is particularly helpful for emergency rooms in rural hospitals where they may not have the adequate in-house specialists to help. And this is something that I don't know if you watch the pit.

SPEAKER_02 9:30

No.

SPEAKER_00 9:30

Okay, but the pit is about an ER. And the ER's job is frankly just to stabilize people.

SPEAKER_02 9:35

Yeah, for sure.

SPEAKER_00 9:36

Right? They are jacks of all trade. They have to, so they actually rely a lot on specialist consults to figure out what to do next after they have stabilized the person. And if you're in a rural hospital, you may not have that specialist consult. And telemedicine helps with that. This area has made big strides in teleneurology specifically for stroke. When someone comes in with a stroke and you don't have a neurologist in house, telemedicine can be very helpful.

SPEAKER_02 9:57

It makes a lot of sense. And this is adjacent to, although not directly the same, which is I had mentioned I had worked as an EMT for a little while. And one of the things we talked about in our training was that people could call into the emergency department to get instructions on what to do to stabilize the patient if it was particularly complicated in the route in. So slightly different version of a console.

SPEAKER_00 10:18

Yeah, just that at a larger scale now, you know?

SPEAKER_02 10:20

Yeah. And not over the telephone. You can actually see people and share images and Yeah, there's a camera now. Yeah, it's amazing. So obviously, we can't talk about telehealth without talking about the single most impactful event in its existence, which is the pandemic. COVID shifted several types of patient-facing meetings virtually, like wellness visits, nutritional consultation, physical and occupational therapy, fertility consultation, post-surgical follow-ups, et cetera. It also dramatically increased the government's interest and every healthcare system interest in investing heavily in telehealth.

SPEAKER_00 10:52

To me, this is the medical equivalent of like people working remotely. It's like, wait, I don't have to go into the office five days a week to do this job. And I think medicine had this similar realization is all these consultations where it's just a provider talking with the patient, they don't have to come in. You could do this over Zoom.

SPEAKER_02 11:08

As I mentioned at the beginning, it's very regular now to you go in, you get some kind of evaluation, maybe you get some test results, and then the follow-ups on telemedicine. You don't need to go in again.

SPEAKER_00 11:18

A more primary care example would be a patient with a weird skin rash that they are worried about. Traditionally, that patient would need to somehow get their butts to the primary care provider. And this is after making an appointment, which thanks to the shortage that we have, it may take days or weeks to get an appointment with primary care, and then have the provider look at the rash. Now, for something simple like a skin rash, the patient can take a picture of said rash, send it via a secure messaging system to their providers for them to look at and then recommend next steps. A lot of medicine is about dealing with the uh, for lack of a better term, the common problems. And yeah, like if we can solve these common problems via telehealth and telemedicine, the actual doctor can do some actual important thing, which kind of sound condescending to the common problems. But you know, they got more important things.

SPEAKER_02 12:02

No, I I think like all things, health needs are on a spectrum from simple to complex. And there are a lot of things that could be handled quickly and efficiently in telehealth or telemedicine versus some other things that require in-person attention. And we have limited resources, so maximizing those resources for the more complex cases makes good sense.

SPEAKER_00 12:23

Very helpful.

SPEAKER_02 12:24

Another key feature of telehealth is remote monitoring and prevention. This is especially helpful for patients with chronic conditions like diabetes or high blood pressure. Instead of telling patients to watch their blood pressure, providers can see it directly. It's also helpful for some people in need of monitoring, like just after major surgery, which can be done at home instead of keeping the patient in the hospital once they've stabilized. And patient education with telehealth is much more convenient than in the previous model. You can fit folks in and get that education done without having to bring people into the building.

SPEAKER_00 12:54

Yeah, especially a lot of people live very far away from hospitals, and especially when the hospital specialized, so that instead of having uh local hospitals, a lot of times, like if you have a particularly complex surgery, you need to go to a major academic center, which could be hours away from where you live. Another benefit of telehealth and telemedicine is that it provides an option for people with mobility issues and perhaps with anxiety issues. If you have agoraphobia, or uh that's the only thing I can think of right now. But I'm pretty sure there's other reasons why people don't want to leave their house, or just financial barriers because you don't have a car or transportation cost. This dramatically shortens that travel distance, meaning you just need an internet connection. And there are many angles to dissect telehealth, but I want to focus on one aspect of it that its proponents love to discuss, which is the impact telehealth has on improving access specifically to underserved or rural communities. Healthcare access is a perennial problem, especially in the United States, not just our healthcare system, but the sheer size of the country as well. The result is several communities facing inadequate healthcare coverages, especially specialty care.

SPEAKER_02 13:55

80% of US counties do not have adequate access to care, which translates to around a third of Americans because population is not distributed equally across the US. Most of these are in rural areas. Healthcare provider shortages at all levels is also a growing problem in the United States. Just physicians alone were expected to be short at least 13,000 doctors in 10 years. And less optimistic estimates are several times this number. In these communities, it could be an hour plus travel just to get to any healthcare service. Obviously, this is bad for medical emergencies, but it also discourages people from seeking regular care, which means small problems can turn into big problems if we're not taking a preventive approach.

SPEAKER_00 14:36

Yeah, and this preventive approach is what a lot of proponents uh really want to hone in on because they know that telehealth can't replace everything. Like if you have a broken bone, you need to go in person, right? That's just there's no way to get around it. But what telehealth proponents for rural health are proposing is that a lot of these people living in these rural communities, the biggest problem is that they don't even go to the doctor at all for like basic things like hypertension, etc. And then by the time they get there, their blood pressure is like 180 or something. And telehealth really can do the prevention piece really well. That's what they're proposing. Now, before we get into the challenges, shall we say, I think it's about time that we answered the obligatory question that we ask in every episode. Why is this public health?

SPEAKER_02 15:18

As we've been alluding to, telehealth improves access. Telehealth can help reach more remote communities or vulnerable populations. The basic preventive care telehealth can provide has a lot of value to these communities. Telehealth is good for prevention. The VA or the Veterans Administration, one of the biggest users of telehealth, reports several positive outcomes from their telehealth endeavors, including dramatic reductions in things like heart failure hospitalization, mental health hospitalization, and other common causes of hospitalization. It improves efficiencies. Telehealth visits have lower follow-up rates than in-person visits, as well as reduce unnecessary in-person visits in general. And telehealth is cost-effective. It's cheaper to operate virtually than in-person. It also saves on transportation costs for the patients. But again, at the heart of it all, public health is about improving the health of everyone. And you can't do that if you aren't reaching everyone.

SPEAKER_00 16:10

Yeah. So let's get into this. There's oftentimes a disconnect between the dream, the ideal of what a technology can do, and what happens when you actually try to implement this technology. So, needless to say, telehealth and telemedicine is going to be a critical part of our healthcare system going forward. But let's talk about some of the challenges, barriers, and critiques of telehealth. First, the obvious, it doesn't fully address healthcare shortages problems. It cannot completely replace in-person care. That much is pretty obvious. Uh remote radiology, like we just described, still requires radiologists. So there is a hard limit on how much telehealth can bridge in terms of shortages. Many lab tests can also be done in person, et cetera, et cetera. But there's another challenge that I think is interesting to discuss and break down a little bit.

SPEAKER_02 16:57

Sure. So the first is induced demand with a lower barrier to healthcare access in the form of video visits, sending secure messages to your doctors. We're already seeing doctors getting flooded with messages from patients.

SPEAKER_00 17:10

Cass, do you think the type of people who send a lot of messages to doctors are they evenly distributed across the demographic spectrum?

SPEAKER_02 17:20

No. Really interestingly, not that long ago, one of our PhD students defended her dissertation and she looked at my chart messages between patients or their caregivers and providers. And it was really interesting to see the distribution. Like there are in the emergency department, we would call them frequent flyers, people who came in all the time to the emergency department. And in this case, it was like frequent messengers, people who would message every day all the time about all of these things and just flood the providers with messages. So, no, I do know that there's some variation in where these messages are coming from.

SPEAKER_00 17:54

Yeah, and that's just one example. But you brought this up earlier. Like, yeah, it's supposed to give access to people in rural communities. But in reality, some of the things that we've noticing with increase in telehealth is that it improves access, but a lot of the bandwidth is being utilized by people who otherwise already have access to traditional healthcare, but now have an even easier access to healthcare because of telehealth. So the distribution of the benefits of telehealth is not evenly distributed. Like a lot of it is still people in affluent areas, cities where they're, you know, within walking distance to a hospital. But honestly, if you can meet with your doctor via Zoom, like you probably wouldn't even want to walk to the hospital. There's still a big challenge in with getting access to these rural communities. A lot of the bandwidth is being taken up by people who I don't want to say already have access because it's a complicated question, but you know what I mean.

SPEAKER_02 18:44

Additionally, some rural hospitals have difficulty accessing high-speed, secure broadband. Telehealth has some high upfront costs to make sure that you've got the resources to be able to actually meet with your patients. Since healthcare information is sensitive, there's data privacy concerns for all the information being sent back and forth. What digital infrastructure are we using? Can we trust the companies behind it? What if patients don't have internet or a device, which is not everybody? Maybe they have to go to a public space to use internet. And what kind of implications does that have for privacy then as well? And then telehealth can be challenging for older individuals or people who are less familiar with technology, which may make it harder to have a meeting with your doctor than going in person.

SPEAKER_00 19:28

Yeah, as much as telehealth has a lot of benefits and potential, we still see a lot of the traditional barriers to healthcare impacting telehealth as well. Data privacy concern goes beyond third-party platform, but personal cybersecurity concerns as well. Like what Wi-Fi network are you using to call your doctors? Does the device you are using have vulnerabilities? Those are all sort of data privacy concerns. And that has nothing to do with the telehealth system, is like the device that the people are using. Are those secure? Other barriers that I found that people in telehealth space are saying that this is the top issues that need to be addressed. Interstate licensing. Doctors in Australia, what are their liabilities if they make a misdiagnosis? Right? How does that work? And doctors can only be licensed in a particular state. Obviously, you can license in multiple states, but it's more licensing that a doctor would need to do. I don't know if there's like a hard cap. Like, is there a limit on the number of states that a doctor can be licensed?

SPEAKER_02 20:18

I have no idea.

SPEAKER_00 20:18

Who knows? But liability and interstate licensing issues, the current reimbursement structure from Medicare and Medicaid are not there for telehealth, which places strain on the rural hospital who needs it the most. So a lot of times, the big academic centers, they see telehealth as a cost-saving measure because they have the resources, they have the upfront investments already. So they will do it, regardless whether Medicare or Medicaid reimburse. But if you're not a large academic center and Medicare and Medicaid don't reimburse telehealth equitably, then you're probably not going to do it, even though it's like in the long run, it's going to benefit you. But again, Medicare and Medicaid plays a huge role on like what gets done because so much funding comes from it. And we talked about this already. Rural communities lack the internet infrastructure to sustain telehealth. A lot of these structural issues still persist despite the vision of what telehealth can bring.

SPEAKER_02 21:06

I think a couple of key things to be thinking about. There is a lot of promise for telehealth. Who uses it and how it gets used has not yet achieved the goals that were set out, but that doesn't mean we should stop. I think we need to go back to sort of what was the original point. And we need to be thinking about providing infrastructure supports because just as we talk about all the time on the podcast about public goods, internet is a public good. We need to make sure that people have access to broadband. And we need to make sure that people living in communities where they already have challenged access to healthcare services are being prioritized for telehealth.

SPEAKER_00 21:46

Yeah, absolutely. Hopefully, we see at least changes in the current reimbursement structure. That's what all the articles that I found, they always cite that as like the number one reason why telehealth is not in more places because Medicare and Medicaid don't reimburse it properly. Which, again, for rural hospital, that's like one of the biggest motivation for why they do or don't do something. But yeah, telehealth is great. It could be better.

SPEAKER_02 22:07

It would be worse if we didn't have it.

SPEAKER_00 22:09

There we go. That's a good message to end on. So micro goods time. I would say my micro good. Do you have one? You leaned in.

SPEAKER_02 22:15

Meditate.

SPEAKER_00 22:16

Yeah.

SPEAKER_02 22:16

And like I know a lot of people are like, oh, I can't meditate. Like I can't sit still for that long, or my brain, like things are always coming into my brain. And there's a misperception that the point of meditating is to not think.

SPEAKER_01 22:26

No.

SPEAKER_02 22:26

The point of meditating is to not hang on to the things that pop into your head. Things pop into your brain, you acknowledge them, you let them go. And it's just a time to focus on your breathing, focus on your body, and center yourself, which I'm going to be doing a lot of meditating this weekend.

SPEAKER_00 22:41

Yeah, meditate is great. Another thing to keep in mind is that donations to whatever causes that you believe in, they do matter, even if it's like small amounts of donation. I recently read an article. It was from like an independent uh journalism platform. And they say like a lot of the donations are like small donations, but they make a big difference. So yeah, donations do matter.

SPEAKER_02 23:00

It adds up. Yeah. Small donations do add up if you've got enough people making them for sure.

SPEAKER_00 23:06

Absolutely. But yeah, telehealth, wonderful. Could be better. Yes. Thank you for listening to everything is public health. New episodes every other week. If you like the show, please tell everyone you know about the show. That helps us immensely. Commenting, subscribing, and leaving us a review helps us a bunch as well.

SPEAKER_02 23:21

If you have any questions or think we missed an important perspective, you can reach out to us at everything ispublichealth at gmail.com. Follow our website, everything is publichealth.com for all show updates and bonus material. And remember, everything is public health.

SPEAKER_00 23:34

Everything is public health.